3 Setting Up A Movement Disorder Surgery Practice

5/16/2015
Bakay, Movement Disorder Surgery, 2009
3 Setting Up a Movement Disorder Surgery Practice
Kopell, Brian Harris, Baker, Kenneth, Boulis, Nicholas M.
This chapter addresses practical considerations in starting and building a neurosurgical movement disorder practice. This effort may entail merely adding deep brain stimulation
(DBS) to an existing general neurosurgical practice; however, it has traditionally implied the creation of a practice focused on functional neurosurgery, usually in the setting of an
academic or large specialty clinic. Because of this association, this chapter addresses both scenarios but focuses on the broader functional neurosurgery practice.
Functional neurosurgery can consist of an intervention to correct aberrant information processing or altered synaptic communication in the nervous system through surgical
ablation (anatomical) or electrical stimulation (physiological) to treat neurophysiological abnormalities. The discipline itself remains loosely delineated with no standard syllabus of
skills and disease targets. This confusion is reflected in the significant variance in training offered by different fellowships. The core of functional neurosurgery includes the
treatment of epilepsy, spasticity, pain, and psychiatric and movement disorders. However, there is a consensus that psychosurgery should be practiced sparingly and with great
circumspection, and some contend that epilepsy and pain surgery are entirely independent disciplines. Finally, the emergence of restorative techniques for neuroprotection, axonal
regeneration, gene therapy, and cellular grafting promises to further obscure the already imprecise boundaries of this discipline.
It is clear, however, that movement disorders alone will not provide a sufficient caseload to occupy most fulltime neurosurgeons. The mix of services offered by functional
neurosurgeons must balance the surgeons' interests with the demand in their individual environment. Thus the demand for DBS may motivate generalists in regions lacking the
service to add these techniques, whereas young functional neurosurgeons with a specific interest in movement disorders may be forced to practice general neurosurgery as the
focused functional practice evolves. Even more than spine or vascular neurosurgery, functional neurosurgery requires an intricate and diverse relationship with a network of
referring physicians as well as a variety of integrated teams. The development of the functional practice usually parallels the evolution of these teams. As the application of DBS is
expanded to other fields additional teams will be needed. Thus, when DBS is used as an alternative for cingulotomy, subcaudate tractotomy, and capsulotomy in the field of
psychosurgery a very different team will be assembled.
Setting up a functional neurosurgical practice poses particular organizational and financial hurdles. This chapter broadly outlines and organizes these challenges. As the technology
of functional neurosurgery continues to evolve, some of the specifics discussed in this chapter will cease to be relevant. We anticipate that the technology will become more user
friendly, making both acquisition and application easier. However, the hope is that the general principles described will continue to be of use in setting up a practice focusing on
movement disorders and functional neurosurgery in general.
Capital Expenses
At present, starting a movement disorder practice can require a considerable capital investment. These expenses will include a stereotactic frame, a stereotactic planning software
package or planning station, and neurophysiological equipment. Individual surgeons will vary in their utilization of these three core products. Frameless stereotaxis and the
integration of these products are trends that may significantly change the nature of the capital expense required to initiate a DBS program. That is, it may become possible to
include the cost of such an integrated system into the implanted devices or for hospitals and practices to lease the systems.
Stereotactic Frames
Because presently framebased stereotaxis remains the gold standard, it is assumed that these devices are essential. Three of the most popular frames will be considered here.
Most commercially available frames have similar accuracies and idiosyncrasies. [1] As such, it is important to choose a frame that will have the most robust company support, ease
of use, and compatibility with computer planning systems.
The Leksell Stereotactic System (Elekta AB, Stockholm, Sweden, www.electa.com )
Globally, the Leksell Stereotactic System ( Fig. 3.1 ) is the most widely used frame. The frame, designed by Lars Leksell in 1949 [2] after his period of study with Spiegel and

Wycis, is the first stereotactic apparatus based on the arccentered principle. Leksell's original description of the principle reads as follows:
Fig. 3.1: Leksell Stereotactic System (Elekta AB, Stockholm, Sweden, www.electa.com ).
“Essentially, it consists of a semicircular arc with a movable electrode carrier. The arc is fixed to the patient's head in such a manner that its center corresponds with a selected
cerebral target. The electrodes are always directed towards the center and hence the target. Rotation of the arc around the axis rods in association with lateral adjustment of the
electrode carrier enables any convenient point of entrance of the electrodes to be chosen independent of the site of the target.” [3]
The current model of the Leksell stereotactic headframe (Elekta Instruments, Inc. Norcross, GA, www.eleckta.com ), the Model G frame, is nonferromagnetic and compatible
with all available imaging techniques, including computed tomography (CT), magnetic resonance imaging and angiography (MRI and MRA), and positron emission tomography
(PET). The base ring is rectangular, measuring 190 mm by 210 mm. [4] The x coordinate is set on the arc, whereas y and z coordinates are set on sidepieces attached to the base
ring. At the center of the frame x = 100 and y = 100 and 0,0 in the posterior right corner. The arc attaches to the sidepieces. The x, y, and z coordinates are initially set before
sterile draping, and the apparatus needed to adjust these coordinates during the procedure is draped out of the sterile field. Thus, to avoid compromising the sterile field, target
adjustments should be done by an individual who is not scrubbed. Frame placement can be easily done on a conscious patient with local anesthesia. Generally, two people are
required for satisfactory placement of the frame. The CT or MRI results can be sent via a network connection to a computerized surgical planning station (SurgiPlan, Elekta). All
major planning software packages include settings to register the Leksell frame. A major advantage of the Leksell frame is its long history of proven use in functional neurosurgery
as well as stereotactically guided endoscopy, brachytherapy, radiosurgery, and the like. A typical assembly includes the base ring, two front pieces, a collection of MRIcompatible
skull fixation pins, and a set of wrenches for pin placement and removal. With some minor variation, the basic set costs $86,000 to $100,000 and includes the Model G
headframe, a set of four posts for pin fixation, a titanium pin set, and the arc system.
The CosmanRobertsWells (CRW) Stereotactic Apparatus (Integra Radionics, Burlington, MA, www.radionics.com )
The second most common headframe used in the United States, the CRW Stereotactic Apparatus is another arccentered system. The CRW frame ( Fig. 3.2 ) is the second

generation [5] of a stereotactic apparatus first developed by Theodore Roberts, Russell Brown, and Trent Wells in the late 1970s. Most contemporary stereotactic frames use some
variation of Brown's vertical triangulation fiducials to convert images to stereotactic space. [6] Like the Leksell frame, it is also a highly versatile, arccentered system and is
compatible with MRI and CT.
https://eneurosurgery.thieme.com/app/reader/html?id=9781604060386&page=16 1/16
5/16/2015
Fig. 3.2: The CosmanRobertsWells (CRW) Stereotactic Apparatus (Integra Radionics, Burlington, MA, www.radionics.com ).
The Universal Compact base ring that is affixed to the skull is ovoid and offers a front piece that allows easier airway management. The arc system and targeting sliders are
separate from the base ring. Because the head ring is separate from the arc, the CRW system offers a major advantage in sterile draping. The placement of the sterile arc on the
head ring in the operating room allows continued sterility and exposure of the anteriorposterior (AP) and lateral (LAT) scales. As a result, target settings and retractor positions
can be easily changed with minimal risk of compromising the sterile field. Another advantage is the availability of a phantom base assembly that allows independent verification of
target coordinates. All major planning software packages, except SurgiPlan, include settings to register the CRW frame.
A typical assembly includes a head ring, the arc system, a universal CT/MRI localizer, a phantom base assembly, and trunnion reticles. Its estimated cost is $85,000. The
functional CRW package includes sidebars for the ears similar to those of the Leskell frame to more easily apply the frame in a rectilinear alignment relative to the skull.
The Riechert/Mundinger (RM) Apparatus
Developed by Fritz Mundinger and Traugott Riechert in 1951. [7] this device is a popular stereotactic system in Europe. The RM frame ( Fig. 3.3 ) is a polar coordinate system

with the target determined by multiple arcs in lieu of being at the center of an arc. The electrode carrier is offset, and it is desirable to use a phantom (or a computer) to adjust
the apparatus. The phantom mechanically simulates the placement of the arc system on the head and the coordinates of the target. Multiple targets require multiple independent
calculations and therefore are slower and more complex than on the arccentered systems discussed earlier.
Using this device, Riechert and Mundinger were the first to execute “open stereotaxy,” in which open craniotomy is combined with stereotactic localization. They also used the
device in pioneering the use of computers and CT imaging in the targeting of stereotactic procedures. This device can be utilized in a variety of transcranial and transfacial
procedures and has also been adapted for radiosurgery. More than 450 of these headframes in over 80 countries are currently in use. [8] However, most planning software
packages do not include settings for registration of an RM frame. This system is no longer commercially available.
Frameless Deep Brain Stimulation
Two alternatives to framebased stereotaxis are currently available. One is the Nexframe system ( Fig. 3.4 ). The other is the StarFix system ( Fig. 3.5 ). Both allow a frameless
solution to DBS and stereotactic lesioning procedures.
Typically, individual CT/MRI compatible fiducials are affixed to the skull prior to surgery. Currently, the only commercially available bonefixed fiducials for frameless stereotaxis is
the Acustar system (zkat Company, www.zkat.com ). Boneimplanted rather than adhesive fiducials are used to eliminate targeting error due to scalp mobility. Each fiducial is
a selfdrilling screw assembly, which allows for MRI and CTcompatible scanning. This process generally involves small stab incisions at each fixation point, done under local
anesthesia. This is usually easier for the patient than stereotactic headframe placement. CT and MRI, as well as target planning, can then be done the day before surgery. The
fiducials must remain affixed and immobile for the period prior to surgery. Although a study comparing the accuracy of DBS electrode placement utilizing frame and frameless
solutions is still ongoing, preliminary data suggest they may be equivalent. [9]
Fig. 3.3: The RiechertMundinger Stereotactic frame.
Fig. 3.4: Nexframe Frameless Microelectrode Recording Guidance Assembly (Medtronic, Minneapolis, MN).
Nexframe Deep Brain Access System
Developed by Image Guided Neurologics (IGN Melbourne, FL, now owned by Medtronic, Neuromodulation [Minneapolis, MN, www.medtronic.com ]) this was the first
commercially available frameless DBS solution. The Nexframe system includes two burrhole locking systems for DBS electrode fixation and a tower assembly that allows for
targeting in conjunction with a variety of stereotactic planning software packages. A microelectrode recording (MER) guidance assembly that locks in the tower assembly is also
available (MicroTargeting from FHC, Inc., Bowdoin, ME, www.fhco.com ).
In this system, only target planning is performed prior to surgery. On the day of surgery, once the tower assembly is fixed to the skull over the burr hole, target trajectory is then
established by a swivel/pivot mechanism on the tower itself by active/passive laser guidance. If there is any need to change trajectory, this can be done intraoperatively. The per
use cost of this system is $1800 for two base rings and one tower. It is currently compatible with several stereotactic planning software packages.
Fig. 3.5: STarFix tripod (FHC, Inc., Bowdoin, ME, www.fhco.com ) coupled to the skull via the Acustar bone markers (zkat Company, www.zkat.com ).
5/16/2015
The STarFix System
This system offers an approach that is slightly different from that of the Nexframe. Utilizing the STarFix (FHC, Inc., Bowdoin, ME, www.fhco.com ) requires fiducial placement at
least 3 days prior to surgery. Target and trajectory definition are done using a proprietary software package known as VoXim (IVS Solutions AG, Chemnitz, Germany), although
efforts are being made to enable the use of other software packages. This information is sent to FHC, where a STarFix system is custom designed for each patient. During surgery,
the STarFix tripod is coupled to the skull via the Acustar bone markers. Note that this system requires the intraoperative application VoXim software as well as a microelectrode
recording system also proprietary to FHC. Finally, the trajectory is fixed for the course of the procedure. Any change in trajectory will necessitate the use of a new STarFix system.
The advantage of this rigidly constrained system is that it eliminates the potential errors in a “movingparts” system. There are some initial upfront costs to this system as
opposed to the Nexframe system. To utilize this system, the VoXim software, Acustar adapters, and microdrive adapters must be purchased for approximately $90,000. In
addition, the FHC microdrive must be used with this system; the motorized version costs $24,000. Each STarFix platform costs $1200. There are several avenues to offset these
expenses. The platforms are patient chargeable. Also, placement of fiducials can be billed as placement of cranial tongs.
The added cost of a frameless solution is partially offset by the safety/comfort advantages and time saved in the operating room (because imaging and case planning can be done
prior to surgery). Also, although the total cost may be more, the upfront costs for such systems as the Nexframeare essentially nil because each device can be obtained on a per
use basis.
Neuronal Recording Systems
Although the importance of intraoperative physiological mapping with respect to optimizing patient outcome is still debated in some circles, [10] – [13] it is commonly considered to
represent the gold standard approach to DBS surgery. This debate and the utility of MER are discussed at length elsewhere in the book (chapter 8). Although no prospective clinical
trials are available to support MER, our group utilizes it for all procedures. Apart from our belief that MER optimizes accurate electrode positioning, it may prove to be important in
building a referral base. Patient support groups and the Internet have served to enhance the dissemination of information about DBS. Thus both patients and referring
neurologists have often been alerted to the variance in application of these techniques. We make a point to explain our view of the importance of MER to both patients and
referring physicians as part of the process of building conflidence and credibility.
Electrical noise in the operating room is one of the greatest inconveniences encountered in initiating a movement disorder practice. In general, minimizing the number of electrical
devices functioning in the operating suite can eliminate noise. Nonetheless, early in the process of developing a practice an MER system should be tested in the operating room
that is to be used for DBS. Some MER systems are more susceptible to noise. Importantly, critical operating room equipment that generates significant noise may need to be
replaced. In some cases, architectural issues may require relocation of the planned operating room (personal experience).
The MER equipment constitutes an additional capital investment, currently ranging from $50,000 to $100,000. Although such systems actually consist of numerous components,
a typical system can be separated into the microdrive and its accessories, the collection of electronics used to amplify and filter the signal, and an oscilloscope and/or highquality
audio monitor. Table 3.1 gives a list of some of the more popular commercially available MER systems. Such systems offer an “allinone” package of the various components
discussed in this section.
Selfcompiled systems, using hardware acquired from various vendors of neurophysiology equipment, can be substantially cheaper than integrated systems. However, this doit
yourself method requires a high level of expertise for both construction and maintenance. Fortunately, prepackaged MER equipment includes both the recording equipment as well
as microdrives with adapters for the Leksell and CRW frames. Slavin recently published a comparative review of the fundamental features of the systems currently available. [14]
However, the quality and nuances of any system should be evaluated carefully, and, where possible, it is best to consult others who have used or are using a given system and to
observe each system in operation.
Many commercially available MER systems are capable of moving up to five electrodes simultaneously. The movement of each electrode is not independent because these systems
rely on a single motor or turn screw to advance and retract the array. If one is considering using more than one simultaneous electrode, we strongly recommend obtaining a
commercially available system because custom design and assembly of such a system are complicated and potentially expensive.
The Microdrive
It is important to consider not only the durability of a microdrive in the face of repeated manipulation and sterilization, but also the ease with which its parts can be assembled
under sterile conditions. This is particularly important for the guide tubes and cannulae. In addition, the drive and its cables must be as light as possible so as not to induce
undesirable torque on the frame system without sacrificing quality. Current drives can be classified as manual, motorized, or hydraulic, with each group having distinct advantages
and disadvantages.
Motorized and hydraulic drive types enable the surgical team to control the action of the drive, and hence the microelectrode, from a remote location. In contrast, manual drives
require the surgeon to advance or retract the microelectrode by manually rotating a turn screw system. This task can be ergonomically awkward and can slow down the process
of mapping, which requires an integration of patient examination, evaluation of the recordings, and adjustments to the electrode position.
Table 3.1 Neuronal Recording Systems
System Name Guideline— Stim Pilot MicroGuide

4000*
Manufacturer FHC, Inc. Medtronic Functional AlphaOmega Engineering

Diagnostics
Distributor FHC, Inc. Medtronic Nicolet (US/Asia)/AlphaOmega

(Europe)
Price Range ($US) $50k$100k $60k$80k $75k$100k
Contact (207) 666–8190 (800) 328–0810 (877) 919–6288
www.fh www.medtronic.com www.alphaomegaeng.com

co.com
* mT Guideline 4000 is in premarket
evaluation.
Motorized drives, which consist of a small electrical motor mounted atop the drive unit, have the advantage of remote control. However, they also carry the potential to introduce
substantial artifact or noise into the recording signal as the microelectrode is advanced or retracted. This rather loud noise has the cumulative effect of delaying the procedure.
First, amplifiers require a small but finite period of time to recover from such artifact. Second, this noise requires that the user advance and stop in a series of steps to isolate
neuronal action potentials. At least one company has attempted to solve this artifact problem by simply “muting” the signal output during electrode movement.
In contrast, hydraulic systems do not generate electrical noise. These systems consist of a slave cylinder placed atop the drive unit. The cylinder is attached to a manual or
motorized master cylinder unit by means of hydraulic tubing. This setup has long been preferred in laboratory neurophysiological applications, enabling remote control while
keeping the motor, if present, sufficiently distant from the microelectrode so as not to induce artifact. Of greatest importance with respect to efficiency, this setup allows for
almost continuous sampling of the trajectory with minimal or no movementrelated artifact. The foremost disadvantage to hydraulic systems is the potential for the hydraulic
tubing to break or leak, releasing fluid that is potentially nonsterile. Further, hydraulic systems tend to require more maintenance, including the constant need to replenish fluid
that has evaporated.
Recording Equipment
5/16/2015
The components of the recording equipment are extremely sophisticated and encompass many individual features. The most important of these features is the quality of the
signal output. Given their impedance, microelectrodes make superb antennae and quite readily pick up extraneous electrical noise. As such, a good MER system must incorporate
both active and passive techniques to shield the signal from noise, as well as subsequent electronics to further filter any pervasive noise. The system should also be simple to
operate. Although most systems now include more sophisticated techniques for analyzing the extracellular action potential data, in most cases little more is needed than the raw
data signal. Because the human ear is often better at discerning a neuronal action potential and patterns of firing than the eye, a highquality audio monitor is again warranted.
The microelectrodes themselves are typically tungsten or platinumiridium metal electrodes with tip exposures of 10 to 20 μm. Platinumiridium metal electrodes are usually
preferred because, in comparison with tungsten electrodes, there is less electrode erosion. Electrode erosion results in impedance changes during microstimulation, degrading
recording quality.
One final consideration to be made when exploring commercial MER systems is the potential application of the equipment, particularly the recording components, to nonDBS
related procedures. Many of the systems currently available are suited, though not ideal, for recording evoked potentials and thus may be used for other types of intraoperative
and outpatient monitoring.
Stereotactic Targeting Software
Stereotactic software allows the movement disorder surgeon to plan the target and trajectory for a given procedure. A surgical planning software system is not an absolute
necessity for a functional practice. Target coordinates for each of the available stereotactic frames can be manually calculated directly from the scanners themselves. However,
commercial planning systems can make the process faster and more efficient.
The most prevalent commercial systems are manufactured by Medtronic, Radionics, Elekta, and BrainLab ( Table 3.2 ). Each has its own limitations and advantages. [15] , [16]

Some are designed specifically for functional neurosurgery, whereas others allow for tumor and spine stereotaxis. These systems provide features that may improve accuracy like
image fusion or corrections for frame misalignments. Further, these systems have features that can save time, including image fusion (allowing MRIs to be done prior to day of
surgery), preset indirect targets, and general software navigation protocols that speed the process. The most important considerations when choosing a software package are ease
of use, compatibility with framebased and frameless systems, and company support.
Table 3.2 Neuronavigation Systems
System Name Treon Plus StealthStation: SurgiPlan/ Leksell SurgiPlan VectorVision: iVision

StealthMerge Module ImageFusion Module
Framelink Module
Manufacturer Medtronic Surgical Navigation Radionics Elekta BrainLab

Technology
Distributor Medtronic Radionics Elekta BrainLab
Price Range ($US) $253,500 (Frame and $100,000– $85,000 (Leksell $250,000 + (Frame and

frameless based capabilities) $120,000 frame based only) frameless based
(Compatible with Nexframe) (CRW/Leksell frame capabilities) (Compatible
based only) with Nexframe)
Contact (877) 242–9504 (781) 272–1233 (770) 300–9725 (800) 784–7700
www.stealthstation.com www.radionics.com www.elekta.com www.brainlab.com
Abbreviations: CRW,
CosmanRobertsWells.
Whether a surgeon is adding movement disorder surgery to a general practice or building a functional neurosurgery practice, the individual's institution may have an existing
imageguided system to which the functional software package can be added. Alternatively, it may be best to purchase an entire system for doing various surgeries, or you may
consider deferring the highercost imageguided platform and purchase a standalone functional system. Prices for a complete imageguided surgical system generally vary
depending on the number of software modules included, but are typically over $200,000. Standalone functional only workstations can be purchased in the $100,000 range.
Editor's Comments
Functional neurosurgeons are not born but created. During residency, stereotactic and functional procedures should be introduced and the concepts grasped. Following graduation,
most neurosurgeons interested in focusing on functional neurosurgery should complete a wellstructured fellowship program. The time, resources, and intellectual activity going
into placement of a DBS lead are far greater than those required for a stereotactic brain biopsy. Although functional and stereotactic fellowships are not yet officially recognized,
they do provide sufficient experience and an intensive work experience to allow sufficient expertise to master all the subtleties necessary for a specialized practice in functional and
stereotactic neurosurgery. During neurosurgical training, an intimate familiarity with a variety of stereotactic equipment should be developed. In starting a new practice, it is
generally this equipment that will be purchased. Nevertheless, it behooves wise neurosurgeons to explore other pieces of equipment because that upon which they were trained
may not be optimal for their new venue. At the same time, inadequate temporizing purchases should be avoided.
Our personal preference is for a metal frame. We recognize in a small practice a plastic frame might be of some value, [20] but they simply do not hold up in highvolume practices.

Nor do I like externally supported aiming devices (Laitinen Stereoadapter, Sandström Trade and Technology, Inc. Wellard, Ontario, Canada, www.sandstromion.cal.noninvasive
stereoadaptor.com ) that are not firmly affixed. [21] I prefer either the Leksell or the functional CRW frame. These are highly versatile, highly durable, and wellestablished
frames with good product support throughout the world. The ear bars are especially useful for aligning the skull and minimizing tilt. Another advantage of the CRW or Leksell
system is the ease with which it can integrate with other addon equipment. I have a great deal of experience with both of these systems, and they are quite useful for routine
stereotactic as well as the most advanced stereotactic and functional neurosurgery interventions.
Specialized equipment such as COMPASS (COMPASS International, Inc. Rochester, MN, www.compass.com ) provides a unique overall system for multiple stereotactic functions,
including functional stereotactic surgery. [22] However, it represents a major commitment of resources that most startup programs are not willing to commit.
The Riechert/Mundinger (RM) system is simple to use and quite versatile. I have little personal experience with using this device, but it reminds me a great deal of the Brown
RobertsWells (BRW) system and the difficulties that arise from a polar system in which movements to multiple targets are much more difficult to calculate. However, it does have
a nice phantom, and the few users that I've had interactions with do like the system. The ZamoranoDujovny frame (F. L. Fischer, Freiberg, Germany, www.flfischer.com ) is an
arccentered stereotactic system that is an outgrowth of the RM system. [23] Similarly, the Talairach system has evolved into several new systems (see chapter 91). [24] In Japan,
the Sugita apparatus (Mizuho America, Inc., Beverly, MA, www.mizuho.com ) has some popularity but no advantages over the systems already discussed. [25]
A great deal of interest has been recently generated by the frameless systems. The initial outline of this book did not contain any information on frameless systems. Unlike the
Polaris system (Ohio Medical Instruments, Inc., Cincinnati, OH, www.ohiomed.com ), these are specifically designed for functional neurosurgery, and most of the preliminary
evaluations have been positive. These are basically plastic systems and for single use. This adds potential cost to these systems, which is already minimally profitable. Frameless
units in the short term for low volume programs are quite reasonable. However, a stereotactic frame costing approximately $60,000 to $80,000 amortized over 10 years is
$6,000 to $8,000 a year. If you are performing more than 10 cases a year the frame more than pays for itself when compared with the extra cost of the disposable frameless
systems ($1800 to $1200 each x 10). Additionally, the extra cost for the disposable frameless platform has to come out of the limited reimbursement under the global cost for
the hospitalization. The saving grace for the hospital is that diagnostic MRI studies can be charged to offset the cost of the frameless systems (see Chapter 10).
The next most important piece of equipment is that of imageguided neuronavigation systems. The more multidimensional the images (axial, coronal, sagittal, and special view,
i.e., trajectory, probe's eye, look ahead, etc.) and the more the trajectories that can be overlaid and annotated the better. Increasingly, the frame systems are developing their
own imageguided platforms. I use both the SurgiPlan (Elekton, Stockholm, Sweden) and the StealthStation (FrameLink Medtronic Navigation, Louisville, CO.) systems. Both of
these are excellent systems, but I prefer the ability to image my trajectories and annotate them with FrameLink. The utility of overlaying brain atlasesis extremely limited and can
be misleading, especially to the novice. Never assume location simply because an overlay would suggest that the location is where you “should be.” I use the image data but
never fully trust them until they are verified electrophysiologically. Although most of the atlases are somewhat adjustable, they simply do not fully confligure the anatomy of the
5/16/2015
patient. An improved imaging quality in the platforms such as edge enhancement and better tissue contrast is preferred to adjustable atlas overlays. I've also seen far too many
poor quality image fusions. As an experiment, I once fused two magnetic resonance images set together, one of which I deliberately invented. It fused and let me proceed as
“verified.” Wise customers will view each platform before choosing the best possible system for their purposes rather than simply the system on which they were trained.
The equipment for the microelectrode is being integrated with the frame systems. Resist the attempt to simply purchase a single onestep, allinclusive frame, imagingguidance
platform and microelectrode system simply because of convenience. Many of the early microelectrode systems have been quite substandard in terms of their signal fidelity and
audio quality. I have had excellent recordings and service with both the Axon (now manufactured by FHC) and the AlphaOmega systems (now distributed by FHC). These systems
are somewhat archaic with their large cabinets. I have also used the FHC MicroTargeting drive that is satisfactory but has problems with artifact from the motor. FHC's disposable
model makes most sense only in very low volume practices. FHC is also supporting the Medtronic Leadpoint MER system. Increasingly, smaller, laptoptype devices are being
developed. The multiple electrode arrays have been slow to catch on in the United States but is popular in several locations in Europe (chapter 9). We've had some limited
experience with multiple simultaneous electrode recording and we would caution the beginner from stepping into this arena too early because listening to multiple channels can be
confusing. FDAapproved commercially constructed microelectrodes are readily available from FHC (MicroTargeting electrodes).
Building a Program
Each subdiscipline within functional neurosurgery requires a multidisciplinary approach. Movement disorder surgery epitomizes this characteristic. Appropriate preoperative
assessment requires neurological, neuropsychological, and neurosurgical assessment. In the operating room, DBS surgery requires both neurophysiological and stereotactic
neurosurgical expertise as well as an anesthesiologist comfortable with the nuances of this operation. Postoperative management requires longitudinal patient relationships that
incorporate internal pulse generator (IPG) programming. Lastly, successful care of this patient population requires open communication between physicians, nurses, and clerical
staff in each of the areas described. Ideally, the knowledge and expertise of several fields should not only interact but merge in a completely coordinated effort.
The degree to which responsibility is distributed to different individuals will depend on the scale of the practice in question. Our highvolume practice currently involves three
neurosurgeons, five neurologists, two neurophysiologists, two neuropsychologists, as well as an ethicist, fellows, nurses, and a variety of other ancillary support staff. This staffing
has been organized with the goal of implanting approximately three DBS patients per week. In the early stages of practice development, or if DBS is to be added to a general
practice, this level of delegation is not practical. Nonetheless, each of the roles described below must be fulfilled. The greatest challenge to initiating a DBS practice is to provide
these various clinical dimensions with the limited resources inherent in an early stage of program building.
The Core Team
In this section, we will attempt to identify the roles and disciplines absolutely necessary to bring a movement disorder patient to surgery. Fig. 3.6 represents the relationships
between these various roles. This sketch will assume that the surgery will take place in a tertiary care, academic medical center. Special considerations for the private practice
model are presented in the last sections.
The Movement Disorder Neurologist
The movement disorder neurologist is usually the first member of the team that a DBS candidate sees. Although fellowship training is available in movement disorder neurology,
there is no specific board certification process for this subspecialty. DBS patients will either come from within the movement disorder neurologist's own practice or from community
neurologists and internists. The next section discusses the referral pool for DBS. As with the neurosurgeon, the movement disorder neurologist should be incorporated into the
preoperative, intraoperative, perioperative, and postoperative segments of care.
The movement disorder neurologist should make the ultimate determination of the stage of a candidate's disease progression as well as the diagnosis. At the initial phase of DBS
evaluation, it is appropriate to take a fresh look at a patient's diagnosis. The movement disorder neurologist should prevent the implantation of patients with multisystem atrophy
or related Ldopa unresponsive coditions. Because these patients are inherently difficult to treat they will often be referred for surgical options. Additionally, the movement disorder
neurologist can help to triage patients who have been referred prematurely. This is a delicate task that is addressed in the section on referral base. Premature referrals for DBS
surgery can embarrass primary physicians and make them hesitant about further referrals. This issue can best be dealt with through an open line of communication between both
the movement disorder surgeon and neurologist and referring physicians.
Fig. 3.6: Core relationship between the surgical movement disorder team.
The most important role of the movement disorder neurologist is to determine whether a patient is medically refractory. The patient's current movement disorder medication
profile and history should be evaluated to determine whether further adjustments are justified. If medications can be further optimized, the team neurologist will communicate
recommendations to the referring doctor and the neurosurgeon. Importantly, the referring doctor and patient should be given an explicit timeline for initiating these adjustments.
We prefer to give patients a delayed surgery date that can be canceled in the event that medical management succeeds. Patients sent back to referring neurologists with
recommendations and no timeline will often be lost to followup either entirely or for long periods. This approach can be frustrating to both patients and referring doctors. Thus we
recommend that the team movement disorder neurologist answer the question, “Is this patient likely to be an acceptable candidate for DBS within the next year?” If so, then
remaining medical options should be exhausted in the time preceding a known date for surgery. This ensures that only appropriate, refractory patients come to surgery, which
also ensures a good relationship with referring physicians and patients. Direct conversations with referring physicians prior to the initial consultation can avoid time lost on poor
candidates.
If a patient is deemed an appropriate candidate by history, medication profile, and disease symptoms, the team neurologist will refer the patient to the surgeon and neu
ropsychologist. The final task of the team neurologist is to orient the patient to the nature of DBS surgery and appropriate expectations for the individual's response to stimulation.
However, an exhaustive discussion of the risks and benefits of surgery and stimulation should be left to the neurosurgeon. In the early stages of setting up a movement disorder
practice, some neurosurgeons may choose to solicit direct, nontriaged referrals. Even in this scenario, a movement disorder neurologist should be enlisted to ensure that all
possible alternatives to surgery are presented and diagnosis is conflirmed.
The movement disorder neurologist can be an essential part of the surgical team. The neurologist can be integral in assessing the correct placement of the DBS electrode by
correlating test stimulation parameters with standardized preoperative ratings. The neurologist will also assess neurological side effects. In our practice, the neurologists control
neurophysiology and bill for the mapping procedure, including MER, microstimulation, and macrostimulation. Individual functional neurosurgeons in smaller practices may choose
to direct mapping with a PhD neurophysiological assistant. This is possible but somewhat awkward and may consequently slow the procedure.
Perioperatively, the team neurologist should be available to assess any changes to symptoms from surgery. We have found that DBS programming through resolving edema in the
basal ganglia can be confusing and inefficient. As a result, we delay programming patients until 1 month after surgery. Consequently, medication profiles are generally kept stable
from preoperative regimens throughout the surgical hospital stay. This is not always possible because microsubthalamotomy may result in side effects (dyskinesias) after surgery
even with doses that were tolerated before surgery. The team neurologist should be integral in guiding medication changes in this period.
Postoperatively, the movement disorder neurologist can assume the point role in programming of the IPGs. Alternatively, the responsibility for programming can be assumed by
the neurosurgeon. As with the intraoperative role of the neurologist, this decision should be made by the surgeon as the practice develops. Programming is a billable procedure
that can support the costs of maintaining this more intensive role in the longitudinal care of the patient. Nonetheless, neurologists are in the ideal position to do IPG programming
because they have the expertise in evaluating movement disorder symptoms and side effects from stimulation and medication. Furthermore, as the stimulation parameters are
titrated toward optimal effect, the patient often requires adjustment in medication profiles. Thus the neurologist is uniquely positioned to coordinate medical and electrical
therapies. In fact, we instruct our patients that DBS is merely a means to deliver focused electrical current, which itself acts like a new drug in the larger treatment regimen. Once
5/16/2015
medications and stimulation parameters have reached a therapeutic plateau, the team neurologist will communicate the current regimen with the referring neurologist/internist.
The referring doctor should reassume the responsibility for pharmacological therapy and can be trained to make minor adjustments to IPG settings. If any major problems develop
or changes need to be made, the relationship between referral doctor and team neurologist will facilitate patient care.
The Neuropsychologist
Although movement disorder surgery can ameliorate the symptoms of Parkinson disease, essential tremor, and dystonia, the operations themselves can affect the patient's
cognitive function. Cognitive changes are well documented potential side effects of ablative surgery. [17] Similarly, despite the potential to adjust and even discontinue stimulation,
pallidal and subthalamic stimulation can cause permanent changes to the intellectual function. [18] In addition, it is becoming increasingly clear that subthalamic stimulation can
induce emotional side effects, including depression and mania. Further, the increased mobility achieved through DBS can cause preoperative manic or impulsive tendencies to
become more destructive. Although the risk of cognitive deterioration and stimulationrelated emotional lability cannot be rigorously determined preoperatively, the best indicator
is the neuropsychological profile of the patient. Any signs of significant executive dysfunction, impulsivity, or dementia should be immediate warnings as to the patient's suitability
for surgery. Movement disorder surgeons should make the final determination about surgical candidacy with respect to information on cognitive function and emotional stability.
However, it is important to have objective documentation of this status based on reproducible metrics prior to proceeding with surgery. Identifying a specific neuropsychologist
with an interest in DBS and Parkinson disease will facilitate this process. In the event that concerns about cognitive and emotional issues develop during stimulation, the
neuropsychologist can be involved in the process of objectively measuring and documenting the change. This collaboration becomes indispensable as one seeks to establish DBS
programs that minimize these side effects.
Also, because movement disorder surgery deals with chronic debilitating disease, psychopathology can develop in both patients and family members as they attempt to cope both
pre and postoperatively. Anxiety and depression are commonly associated with the disease. Further, the vast improvement in the function of movement disorder patients after
surgery can have a significant impact on patients and their support system. The patient's primary caretaker, once heavily depended on for support, may require help dealing with
a changed role. The neuropsychologist may help to anticipate these problems, detect them when they occur, and make treatment recommendations.
The Neurophysiologist
Although it is common for a functional neurosurgeon to take an active role in deep brain mapping, it is commonly performed in conjunction with an MD or PhDlevel
neurophysiologist with substantial experience in electrophysiology, physiology, or neuroscience. Although experience in the physiology of motor control is useful, the team
neurophysiologist should have a working knowledge of the regional anatomy and electrophysiological characteristics of MER in the target site(s) and surrounding structures.
Characteristics studied include neuronal waveform, discharge pattern, discharge frequency, changes in activity with sensorystimulation (light touching of skin, palpation of muscle,
movement of limbs), and changes in activity with behavior. Optimally, training should consist of a 1year fellowship in intraoperative MER techniques, covering required knowledge
and skills; however, this is not always practical. At a minimum, the neurophysiologist should have a robust understanding of the principles of differential amplification, impedance,
and the Nyquist theorem, as well as the safe operations of electronic equipment related to micro or semimicroelectrode recordings, including amplifiers, filters, and
microelectrodes.
Because accurate electrode placement depends on effective mapping, someone in the operating room must be comfortable with the equipment. That individual is responsible for
maintaining and trouble shooting the equipment as well as deploying it in the operating room. Technical difficulties with the equipment in the operating room require an
experienced, dedicated individual capable of effcient troubleshooting. This includes searching out and reducing the electrical interference that is present in every operating room.
Outside of the operating room, the neurophysiologist ensures that all of the technical equipment is in working order and in good repair. This person also interacts with vendors
and bioengineering personnel to enact upgrades and repairs as technology/resources allow. Also, in an academic center, the neurophysiologist will be essential in investigational
efforts involving the recorded MER data and functional imaging studies. The degree to which an individual surgeon starting a movement disorder practice takes on this
responsibility will again depend on available resources. As more integrated and userfriendly mapping equipment becomes available, this role may be assumed by the
neurosurgeon in lowvolume practices. However, at the present time, having a team neurophysiologist is critical to most higher volume practices.
The Nurse Practitioner/Physician Assistant
This role is extremely important to the smooth operation of the movement disorder surgery practice. A nurse practitioner/physician assistant (NP/PA) becomes a partner to the
functional neurosurgeon in managing this complex and needy patient population. The NP/PA often serves as the main interface between the patient and the neurosurgeon and
will likely be more accessible than the busy surgeon. Together with the neurosurgeon, the NP/PA will see the patients preoperatively, establish a rapport, deliver support
throughout the operative experience, and see the patient postoperatively. The NP/PA should be the first person on the team that the patient will contact with any question or
problems. Thus it is important that the NP/PA is intimately aware of the DBS procedure. This includes indications, the procedure itself, and, importantly, postoperative
complications.
If the surgery takes place without resident support, the PA/NP can often serve as first assistant during the headframe or fiducial placement, imaging acquisition, and DBS
electrode implantation. In our practice, the neurosurgical NP assists with head frame placement and shepherding the patient through preoperative MRI and CT scanning. The PA/
NP then takes the patient to the operating room while stereotactic planning is performed. As discussed earlier, frameless stereotaxis may obfuscate the need for stereotactic
planning on the morning of surgery. However, using the framebased approach, a postframe CT must be obtained even if image fusion is to be utilized. In our practice, the NP has
often assisted with comforting the patient throughout the procedure. Many DBS patients will experience transient confusion during the operation. This phenomenon is often
attributed to the mild pneumocephalus that occurs during surgery. Although not precisely understood, it occurs more frequently in older patients with more advanced disease. The
presence of an individual with whom the patient is well acquainted, who can provide continuous encouragement and orientation, is often critical to completing the case.
In smaller movement disorder practices, particularly ones that are integrated with a broader program of neural augmentation, the neurosurgical PA/NP may play the central role in
IPG programming under the guidance of a neurosurgeon. Because this individual may play a similar role in the management of intrathecal pain and spasticity pumps, as well as
neural stimulators for pain management, they are often already comfortable with the equipment and basic knowledge necessary for IPG programming. As mentioned earlier, in
our practice, IPG programming is largely delegated to the team movement disorder neurologist. In this setting, however, NPs conduct most of the handson programming under
supervision, whereas the neurologist focuses on patient evaluation, medical management, and troubleshooting. In either scenario, as time passes, the number of patients
dependent on the practice will continue to increase given the longitudinal relationship necessary. Thus, in the absence of a skilled PA/NP, the movement disorder neurosurgeon's
time will become increasingly occupied with IPG programming, which affects the neurosurgeon's surgical productivity.
Secretary/Patient Liaison
The role of handling appointments and scheduling is common to any medical secretary. However, two features distinguish the demands on a medical secretary in a movement
disorder surgery practice. First, navigating the ambiguities and intricacies of reimbursement for DBS remains difficult. More time spent with insurance companies means less time
for patient care. Until recently, DBS for subthalamic nucleus stimulation was not approved by the US Food and Drug Administration (FDA). There are future applications of DBS
that are still not FDA approved. Examples include DBS for epilepsy, pain, and psychiatric disorders. We expect the demand for these procedures to increase prior to FDA approval.
DBS for dystonia is approved by the FDA under the humanitarian device authorization but requires an Investigational Review Board (IRB) approved protocol. Getting insurance
company approval for treatment requires negotiation with labyrinthine systems that are as unique as the different managed care companies they serve. A secretary with some
expertise in this area can facilitate this process.
Second, the movement disorder surgery secretary must effectively field the pre and postoperative outpatient calls. DBS is offered to patients who range from well informed to
mildly cognitively impaired. We emphasize that this is a very needy population with whom communication is not always easy. Further, because DBS is elective, a successful
practice must cater to the patient. Unlike many of the segments of neurosurgery, patients and families have the liberty to shop for the movement disorder program with which
they are most comfortable. Patient access and communication is one of the most critical components to achieving this comfort.
Finally, the movement disorder surgery secretary can serve as a layperson liaison. Patient support groups are often an essential part of the movement disorder surgery experience
for the patient. A strong relationship between the practice and these groups, facilitated by the secretary, allows the patients to get the continuing adjunctive support they need
and also offers fertile ground for future patients. Finally, for the present, DBS remains novel to the general public. Thus movement disorder surgery practices may be approached
by the press with the desire of covering “the story” of these patients and the technology. As will be discussed, such coverage can play an important role in practice building. An
articulate secretary knowledgeable in the rudiments of movement disorder surgery can facilitate this process.
The Neurosurgeon
We believe strongly that the movement disorder surgeon must be the team leader. Given that the surgeon must make the ultimate decision concerning who receives surgery and
where the electrode will be placed, he or she must command the respect of the team. As such, the surgeon must not only perform the procedure itself but must also be involved
in all aspects of care. Depending on the model of the practice and the resources available, the surgeon will need to assume each and every role defined earlier as the
circumstances dictate.
In our practice, the neurosurgical preoperative consult focuses on the patient's emotional, cognitive, and medical ability to tolerate surgery. We assess the patient's primary
symptoms and expectations in an attempt to determine whether DBS will benefit the patient. Further, we educate patients as to what will be demanded of them on the day of
5/16/2015
surgery and afterward, as well as the risks of surgery, neural implants, and stimulation itself. Finally, we review the team neurologist's assessment of whether the patient has
exhausted reasonable medical options. Due to the size of our team, we have found that a weekly team meeting is useful to establishing consensus about candidacy as well as pre
and postoperative management.
During procedures, we encourage an open discussion of physiological data (but not in the patient's presence), prior to deciding on new electrode tracts. Nonetheless,
disagreements often remain concerning these data. The final decision concerning target adjustments must always be the neurosurgeon's. Thus efficient and accurate
interpretation of these data ultimately outweighs the technical demands of movement disorder surgery.
Adjunct Medical Fields
Other medical fields will be essential in the execution of movement disorder surgery. Although not a part of the core team per se, they will have an ongoing relationship with the
neurosurgeon.
Anesthesiology
Many of the procedures in movement disorder surgery can present unique challenges for the anesthesiologist. It, therefore, becomes important that the movement disorder
neurosurgeon and the anesthesiologist have a particularly strong line of communication. Often, movement disorder patients are older and, because of their disease, more infrm
than others in their age group. With few exceptions, the operations are performed awake, with only occasional intravenous (IV) sedation. The lack of general anesthesia takes an
element of control away from both the anesthesiologist and the neurosurgeon. Airway issues are of primary concern because the patient is often immobilized in a bulky
stereotactic headframe. Pain control and patient comfort often require a delicate balance because sedatives often exacerbate the airway issues and interfere with MER acquisition.
The anesthesiologist who is better educated about the mechanics of a given movement disorder procedure will be more able to provide an atmosphere of control in the operating
theater. Also the anesthesiologist must have a working knowledge of the impact of various medications on neuronal activity as measured by electrophysiology. This
understanding is essential to maintaining patient control, safety, and comfort without negating MER.
Neuroradiology
Image acquisition is central to movement disorder surgery. Excellent anatomical images can help cut down on MER recording passes and ultimately lead to a safer procedure.
Further, neural imaging in the presence of implanted stimulators requires an understanding of parameters for safelyapplying MRI. This imaging plays a critical role in targeting
previously implanted patients as well as evaluating complications or DBS failures.
Although MER is currently indispensable, advances in imaging technologies may diminish its future role. Diffusion tensor imaging, connectivity imaging, and advances in functional
MRI (fMRI) sequences may ultimately allow the neuroradiologist, together with the neurosurgeon, to defne a movement disorder surgery target [fore the patient enters the
operating room. Such an endeavor would necessarily result in a shorter operation, thereby conserving resources and providing a safer experience for the patient. Thus the
neuroradiologist will play an important role in advancing DBS technique.
Psychiatry
As already mentioned, movement disorder surgery can have significant emotional and psychodynamic consequences. The targets involved in movement disorder surgery can have
significant modulatory effects on aspects of mood. [12] Improved patient mobility can render preoperative impulsivity potentially dangerous. As the patient deals with the return of
function and the patient's family members deal with changes in their own relationship to the patient, psychiatric assistance may be necessary. Thus it is useful for the movement
disorder neurosurgeon to locate a psychiatrist with an interest in DBS who is familiar with these issues and can address them as necessary. This individual plays an expanded role
in a functional neurosurgery practice that includes psychosurgery.
Bioengineering
Many academic medical centers have a bioengineering department. Often these facilities will have the expertise for diagnosis and repair of the expensive equipment essential to
movement disorder surgery. Importantly, because each operative center has its own unique challenges, this department can help in the modification of standard equipment to
optimize resources. As discussed, the team neurophysiologist is the member that must interact with bioengineering most commonly.
Vendors
The movement disorder surgeon should maintain some connections with the vendors of equipment used in movement disorder surgery. These companies often provide training
and expertise that can fill gaps in the team's knowledge base. Not only will this keep the surgeon apprised of advances in equipment, it also offers an interface for reciprocal
improvement. In addition, vendors of IPGs and electrodes depend on the surgeon's productivity and may help to interface with referring neurologists. This role may include
providing support for simple IPG programming in these neurology practices. By maintaining communication with the vendors, neurosurgeons can help to steer research and
development in a clinically relevant direction.
Editor's Comments
Unquestionably, the three most important people in building a program are the neurosurgeon, the neurologist, and the nurse practitioner or physician assistant to manage the
program. The neurosurgeon and neurologist must be emotionally and scientifcally compatible. There is always a tendency for a neurosurgeon to want to proceed with the
minimum amount of data and a tendency for a neurologist to want too much data. Compromises by both parties are necessary. In terms of managing patients and determining
who should go on to be evaluated as a surgical candidate, the neurologist is clearly the leader. The neurologist manages these patients before and after surgery and has the best
handle as to who is a good candidate and who would be a poor candidate based on the patient's disease and psychiatric makeup. The neurosurgeon of course will make the
ultimate decision as to whether to proceed with surgery on any particular patient. Many times the neurologist's opinion is colored by factors other than those strictly related to
surgery. The neurosurgical evaluation is critical and represents a different aspect of the evaluation; hence this book devotes two chapters (Chapters 4 and 5), one by a neurologist
and one by a neurosurgeon, to preoperative evaluation of patients. The neurosurgeon and the neurologist will often have multiple roles in surgery. Sometimes the microelectrode
recording will be performed by the neurologist and sometimes by the neurosurgeon. Both should work together in examining and evaluating the electrophysiological and clinical
data. A second voice is extremely useful in the operating room; however, it must be remembered that the neurosurgeon is the final arbiter and makes the final decisions. It is the
wise neurosurgeon that will take the counsel of the neurologist, though ultimately it is the neurosurgeon's experience and artistry that will finally determine the success of the
procedure.
An experienced and compassionate nurse practitioner or physician assistant is necessary to help in all aspects of the pre and postoperative care of the patient. Frequently, this
person's appearance in the operating room is useful for the patient, especially during long, complicated cases. These individuals can also serve to record data and act as a liaison
between neurosurgery and neurology. The ancillary members of the team also need to be as expert as possible because there are many characteristics of these patients that
require special consideration and evaluation in the performance of the surgery. The smoother the team's performance, the happier will be the patient, the better will be the
selection process, and the better will be the ultimate results.
The Business of a Movement Disorder Surgery Practice
Once the equipment is procured and the team assembled, the practice faces several challenges. The patients must be found. Once found, the practice must be run in an
economically feasible manner for the surgeon, the supporting team members, and the hospital/medical center. The strategies outlined here can address these challenges. Fig.
3.7 summarizes the various avenues of patient referral sources.
The movement disorder population is a large, relatively untapped patient source. Taking the three top indications for movement disorder surgery, one can get an idea of the
numbers of potential cases. Communitybased epidemiological studies have found the prevalence of essential tremor to be as high as 3.9% of the population, with estimates as
high as 5.5% in patients over 40 years of age. [19] The prevalence of dystonia has been estimated to be 3.4 per 100,000 for generalized and 30 per 100,000 for focal subtypes.
Parkinson disease may affect ~650,000 Americans and 1.6 million people worldwide. Based on the incidence of the disease, there are estimates that ~33,000 people worldwide,
including 13,000 Americans, could benefit from Activa Parkinson's Control Therapy each year. The total current population of essential tremor/Parkinson disease patients that are
surgical candidates in the United States is estimated to be 180,000. Since 1997, more than 14,000 people worldwide have benefited from Activa Therapy for essential tremor and
Parkinson disease. [11] Severe spasticity resulting from cerebral palsy, spinal cord injury, and multiple sclerosis as well as a variety of less common disorders may benefit from
surgery. Between 1992 and 2000, ~11,000 intrathecal pumps were implanted for baclofen delivery. Building a successful movement disorder practice depends on finding these
patients.
5/16/2015
Fig. 3.7: Summary of the various avenues of patient referral sources.
The movement disorder surgeon's relationship with local general neurologists is the most important means of generating referrals. Developing this relationship requires a
concerted effort and remains complicated. Because of the novelty of neural augmentation, local hospitals remain interested in hosting movement disorder surgeons to give grand
rounds. Similarly, local and state organizations of neurologists may provide venues to reach out to referring neurologists. These presentations serve to build the surgeon's
credibility with the local neurological community.
However, in our experience, primary physicians refer their patients predominantly to individuals with whom they have a personal relationship. These relationships must be
cultivated by the movement disorder surgeon in the early stages of practice building. As mentioned earlier, device vendors have a shared interest in cultivating these relationships
and are often willing to support introductory dinners or meetings. Many referring neurologists lack the knowledge base necessary for effective referrals. The referral process can be
a nowin situation for these individuals. Inappropriate referrals result in the patients' expectations being raised and ultimately disappointed. This process undermines the patients'
conflidence in their primary neurologist. On the other hand, neurologists fear that patients who undergo implantation will be lost to their practice. Thus, whether the patient is
appropriate or inappropriate for DBS, many neurologists perceive that their practice will be adversely affected by the referral. This cycle can be overcome by establishing a personal
relationship with the primary neurologists. Phone calls should be encouraged to discuss possible referrals. This process educates the neurologists and cuts down on wasted
consultations with poor surgical candidates. Further, it provides the primary neurologists with the opportunity to leverage this relationship, enhancing their stature in the eyes of
their patients.
Likewise, a personal relationship can address the primary neurologist's fear of losing patients who undergo implantation. Within the context of this relationship, these neurologists
can be incorporated into the process of medical adjustment that will occur as IPG programming proceeds. Thus DBS implantation expands rather than limits their role in
management. Finally, in some cases, these neurologists can undertake IPG programming as a billable part of their practice. The device vendors provide education and support in
this process.
As mentioned earlier, both patients and neurologists can be reached through interfacing with the local media. The appeal of DBS technology persists and makes good public
interest subject matter. More importantly, the stark contrast of patients' symptoms before and after DBS, and the ability to recapitulate this contrast by turning off IPGs, creates
astory that is easy for the public to understand. The marriage of high technology with manifest human relief continues to attract publicity. This publicity builds credibility with both
neurologists and patients. It may also reach patients who are not currently receiving appropriate therapy. It is important to point out, however, that raw publicity is a double
edged sword. The selfreferrals that this activity generates will contain many patients that are not appropriate for surgery. The team movement disorder neurologist can be of
significant assistance in triaging these individuals.
With the advent of information sharing technologies such as the Internet, patient support groups and disease societies provide a wealth of information for patients regarding
treatment for their disease. One aspect of this resource is a list of physicians who provide movement disorder surgery. Getting involved with these patient groups by providing
information and speaking at informational sessions can help make the patients aware of a particular practice and its technical expertise in treating movement disorders. These
organizations can serve to connect new movement disorder surgeons with the specific organizations active in their practice area. We have paraphrased the descriptions of these
organizations that appear on their Web sites below.
National Parkinson Foundation (www.parkinson.org )
The National Parkinson Foundation was founded in 1957 by a Ms. Jeanne Levey. Headquartered in Miami, Florida, the NPF supports researchers; physicians; occupational, physical,
and speech therapists; and psychological counseling. It also provides educational and medical information for Parkinson patients, their families, neurologists, and general medical
practitioners.
American Parkinson Disease Association Inc. (www.apdaparkinson.org )
The American Parkinson Disease Association Inc. was founded in 1961 to “ease the burden and find a cure” for Parkinson disease. Headquartered in New York, the organization
focuses its energies on research, patient support, education, and public awareness of the disease. In 2003–2004, the APDA budget for research was more than $2.5 million and
exceeded $2 million for patient support. Each year the APDA scientific advisory board reviews grant requests and submits recommendations for funding researchers whose work
shows promise of making scientific breakthroughs or finding improved treatments for Parkinson disease. The APDA national office also coordinates the efforts of 65 chapters, 57
information and referral centers, and 250 affiliated support groups across the nation.
Parkinson's Disease Foundation (www.pdf.org )
Located in New York and Chicago, the PDF is a national notforprofitorganization, a leading presence in the field of Parkinson disease research, education, and public information.
The organization has an annual budget of more than $6 million and maintains corresponding relationships with 100,000 Parkinson families and friends.
Rewired for Life Foundation (www.rewiredforlife.org )
ReWired for Life Foundation is a nonprofit organization created to promote the understanding of DBS among patients, their families, and medical professionals through
dissemination of information, patient support meetings, medical professional meetings, and research development.
International Essential Tremor Foundation (www.essentialtremor.org ):
The International Essential Tremor Foundation (IETF) was created in 1988 to provide information, services, and support to individuals and families affected by ET. The organization
encourages and promotes research in an effort to determine the causes, the treatment, and, ultimately, the cure for ET. IETF is the only worldwide organization dedicated to
meeting the needs of those whose daily lives are challenged by ET.
Dystonia Medical Research Foundation (www.dystoniafoundation.org ):
The Dystonia Medical Research Foundation was founded in 1976 by Samuel and Frances Belzberg, of Vancouver, Canada, after their daughter was diagnosed with dystonia.
Dedicated to serving the needs of all persons affected with dystonia and their families, the Dystonia Foundation has grown from a small familybased foundation to a membership
driven organization of close to 32,000 persons. The overall membership of the Dystonia Foundation consists of individuals living with all forms dystonia, their friends and families,
health care professionals, and researchers. It is multifaceted and broad in its perspective, uniting people on all levels to better serve those living with dystonia.
Huntington's Disease Society of America (www.hdsa.org )
Soon after the legendary folk singer Woody Guthrie lost his battle with Huntington disease (HD), his widow, Marjorie, sought out other families affected by this devastating
disease. In 1967, this handful of dedicated volunteers formed the Committee to Combat Huntington's Disease. Today, the Huntington's Disease Society of America (HDSA)
continues the mission that Marjorie Guthrie began. HDSA has grown into a national organization consisting of 32 communitybased volunteer chapters, two national field
directors, and a national office that provides leadership, support, and guidance for HD families through a national network of volunteerbased chapters and affiliates as well as
through their newly created Centers of Excellence.
Professional Societies
Another aspect of networking for the neurosurgeon looking to set up a movement disorder practice is the professional society. The professional society allows the movement
5/16/2015
disorder neurosurgeon a forum to exchange the latest scientific and clinical advancements. Having the latest in information is essential to the movement disorder surgeon, and
these societies can be helpful in achieving this goal. Although there are many such societies, we describe the two major groups.
The Movement Disorder Society (www.movementdisorders.org )
The Movement Disorder Society was founded in 1985 on the initiative of Professors Stanley Fahn and C. David Marsden, whose leadership and vision guided the expansion of
clinical expertise and research in this field. This is an international multidisciplinary society of clinicians, scientists, and other health care professionals who are interested in
Parkinson disease, related neurodegenerative and neurodevelopmental disorders, hyperkinetic movement disorders, and abnormalities in muscle tone and motor control.
American Society for Stereotactic and Functional Neurosurgery (www.assfn.org )
Administered through the Joint Section on Stereotactic and Functional Neurosurgery of the CNS and AANS, this is a neurosurgeonspecific organization that provides a forum for
the review of the basic form and function of the human nervous system to improve stereotactic and functional neurosurgical procedures that alleviate human disease and
suffering through diagnosis or treatment of the function of the nervous system. As such, movement disorder surgery is a significant focus of the group, which holds biannual
meetings.
Essential tremor and focal dystonia present specific challenges with respect to generating referrals. Although referrals from neurologists will form the bulk of Parkinson DBS
candidates, many patients with essential tremor and focal dystonia are not in the care of a neurologist. These patients may have symptoms that limit their lifestyle or
employment, but they may remain in the care of a generalist who is not aware of modern movement disorder surgery. The Internet, media, and patient support groups may
facilitate outreach to these patients.
Reimbursement: Special Considerations
Awareness of the various physician and facility reimbursement scenarios is critical to practice development. There are three reimbursement codes that are relevant to most
stereotactic movement disorder operations. The first code is for the frame placement, craniotomy, surgical planning, and implantation of electrodes. The second, is a
reimbursement code for intraoperative testing and evaluation. This code may be billed by the neurosurgeon if he or she does this testing but cannot be billed redundantly if a
neurologist or other individual is billing for that service. Finally, there is a followup and DBS programming code. Of course, this code will be utilized by the member of the
movement disorder team that is responsible for this task.
Current professional billing practice in the United States is based on the Resource Based Relative Value System (RBRVS). Each procedure is given a current procedural terminology
(CPT) code by a board made up of members from the American Medical Association, the medical insurance industry, and the Centers for Medicare and Medicaid Services (CMS).
Each CPT code is assigned a Relative Value Unit (RVU), which takes into account the effort involved in the procedure, the utilization of resources, and the risk of malpractice
litigation. Each area of the country has a particular conversion factor (CF); a monetary value that, when multiplied by the RVU, gives the reimbursement for a particular
procedure.
In the past, the CPT codes applying to functional neurosurgery underestimate the effort involved in many of the procedures, and many codes have not been updated to account
for the evolution of procedures, which have grown more complex and time consuming. In addition, these codes did not take into consideration the cost of expensive implants
required for neural augmentation. Recently, however, progress has been made in this arena. The previous CPT code for a bilateral DBS implant, 61862– 50, was assigned an RVU
of 29. In 2004, code 61862 was deleted and replaced by a new set of CPT codes, which recognized the use of MER. These new codes, 61867 and 61868, represent a RVU of 39.3,
and an increase of 35%. In 2004 there are four variations of that reimbursement code depending on the number of electrode arrays (1 or 2) and whether microelectrode mapping
was used. Because of this, the reimbursement code for intraoperative testing and evaluation (codes 95961 and 95962) can no longer be billed by the neurosurgeon but can be
billed if a neurologist or other individual is performing that service. Implantation of the IPG is billed as 61885 for one electrode array or 61885–50 for two, but Kinetra has a
separate 61886 code that is less than bilateral IPG placements. There is also a new set of followup and programming codes that may be performed by neurosurgeons on occasion
but are most commonly performed by the neurology team (Chapter 13).
Facility reimbursement basically comes in two forms for movement disorder surgery—inpatient and outpatient. Lead implantation is currently only allowed in an inpatient setting.
Depending on patient complications and comorbidities, the inpatient implantation of electrodes maps either to DRG001 or to DRG002. Estimatedaverage hospital payments for
those DRGs under Medicare are approximately $22,062 and $12,851, respectively. Therefore, it is critical to document the comorbidities of movement disorder patients. Given the
demographics of Parkinson disease, many of the patients will qualify for DRG001.
Implantation of the IPGs can be done either within the inpatient admission, and thus be included within the DRGs mentioned previously, or within a separate outpatient
admission. In the case of the outpatient admission, the 2004 Medicare reimbursement is approximately $25,217 for a bilateral IPG implantation. This regulatory idiosyncrasy has
led to most surgeons electing staged implantation. Nonetheless, because the cost of DBS hardware alone exceeds the DRG002 reimbursement level, hospitals may lose money
unless it is staged. Medtronic provides a reimbursement assistant hotline (800–292–2903) and there are helpful Web sites (www.medtronic.com , www.prscoding.com , or
www.cms.hhs.gov ).
Editor's Comments
We must also remember that medicine, despite its scientific basis and artistry, is also a business and must be run like a business. Begin by assessing the potential climate before
starting a practice ( Table 3.3 ). Be sure of the support by both the neurosurgery and neurology departments for the functional surgery program and a cooperative intraand
intergroup dynamics. Beware of halfhearted neurology support when their true allegiance is to more and bigger drug studies. Understand the reimbursement strategies and how
to optimize them. The revenue generation can be modestly lucrative for the hospital and the physicians, if the appropriate fiduciary responsibilities are taken. In the everchanging
Medicare sphere, one must be very cognizant of where small amounts of benefits may be had. Be sure the billing is done properly ( Table 3.4 ). The profitability to the
neurosurgeon can be increased by using the appropriate billing codes. These codes changed in 2004 and are listed in Table 3.5 . The new codes differentiate for single or dual
lead placements with or without microelectrode recordings. Microelectrode recordings can now be billed, and there is a small increase in payment. Thus the increased time required
for the microelectrode recordings is included in this billing. However, the neurosurgeon can no longer bill separately for microelectrode evaluations (95961 or 95262). Because this
is usually done by a neurologist, it can be profitable for neurologists, and they will thus be more readily of assistance in the operating room. I would add fluoroscopy conflirmation
of the probes to surgery (CPT code 76003). It is not only useful in determining the position of the DBS lead but also in recording position of the microelectrodes throughout the
procedure. Thus some of the information that would seem somewhat inconsistent can be corrected by realizing that the microelectrode did not go precisely where directed. The
reimbursement for this is relatively small but can be useful when the profitability of the procedure is small.
Table 3.6 demonstrates the numbers generated by a hospital in 2003. Depending on the particular diagnostic code and how the surgery was performed, profitability for a single
DBS lead placement and generator to the hospital could vary from plus $8,000 to a negative $10,000. Add to this the bilateral generators and considerable loss can result. Thus
performing the surgery in two stages and passing through the equipment cost in an outpatient procedure dramatically increases the profitability to the hospital and makes the
hospital's interest in your surgical performances at that facility far more likely than if your surgery is losing money on a consistent basis.
In addition to working with the hospital, work with the community to build a practice. Outreach to the support groups for a variety of neurological diseases in which the functional
neurosurgeon may interact is not only useful for developing the practice but is also quite helpful in developing an understanding of what is valuable within this community.
Supporting these organizations will ultimately also result in support for your continued practice. A little philanthropy can go a long way in building goodwill. Getting out into the
community hospitals is also quite useful in developing a practice. Try to position yourself as the expert in the field by holding seminars and providing grand rounds not only in your
hospital but also at local hospitals. Never refuse a chance to present your work. Work with the hospital or institutional marketing department and have them help track your
market penetration. Have a Web site that patients can find on the Internet that features your work.
Make a point to meet and socialize with colleagues in the hospital and clinic. A few wellspent minutes in the cafeteria may send referrals your way. Pay attention to where
referrals originate. Responding quickly and appropriately to them goes back to the basic principles of availability, affability, and accountability to build good working interactions
with your referral base. Never say no to consultations. Be sure your clinic is patient friendly. Make sure the staff is courteous, caring, and professional. Patients want an efficient
and professional neurosurgeon who cares about them as a person. Efficiency does not mean cutting short patient questions. Don't keep patients waiting by routinely overbooking.
Fully explain cancellations. Most importantly, treat patients as you would like to be treated. Frequent patient complaints can lose a referral base. Patient surveys or even a call to
your office by a friend trying to set up an appointment can be an eye opener to identifying problems.
Timely communications are a real asset in building a referral base. Nothing irritates a referring physician more than not hearing from the neurosurgeon, especially if the physician
has to deal with the patient in person or on the phone before the followup letter arrives. Academic centers are especially poor at getting dictations done quickly or getting letters
typed promptly. Two or 3 weeks later the “problems” may result in a lost referral source. A quick phone call, email, or fax helps. It is important to give patients handouts, and it is
a good idea to provide educational material to the referral physician, at least the first time a specialty problem is referred and especially if there is a difference of opinion as to
optimal treatment. Do not get the reputation of being a “cowboy.” Be sure your early cases are ideal candidates. Ultimately, the results of your surgery will be the greatest
determinate as to whether continued referrals are made to your practice.
Table 3.3 Assessing the Facilities and Support
5/16/2015
What is the size of the market? (Typically functional neurosurgery needs about 1 million people.)
What is the willingness of the hospital/institution to pay for specialized equipment for functional neurosurgery?
Has there been an increase or decrease in neurological procedures in the group or institution, based on previous years?
What are hospital admission volumes for movement disorders?
Is there a movement disorder specialist and a movement disorder clinic in the group or institution? Are they interested in
developing a functional surgery program?
Who are your competitors (both functional and nonfunctional neurosurgery)? Which hospital has the biggest market share of the
neurosurgery market?
What are competitor hospitals and groups' reputational strengths and weaknesses?
How can you differentiate yourself, based on these strengths and weaknesses?
What are the opportunities for functional neurosurgery procedures, based on the medical dynamics that currently exist?
Is a neuroradiologist available?
What is the availability of computed tomography, magnetic resonance imaging, singlephoton emission computed tomography,
and positron emission tomography?
Is anesthesia with expertise/interest in neurological patients preferentially assigned to neurosurgery?
Is specialized rehabilitation readily available for movement disorder patients?
What is the availability of physician extenders (i.e., physician assistants, nurse practitioners)?
What is the willingness of the hospital/institution to pay for a dedicated biller/coder, secretary, or physician extender?
Table 3.4 Collection Tips
1. Do not assume billing staff understands functional neurosurgery coding. You are the only one who truly knows what you did in
the operating room. Know the current procedural terminology (CPT) and diagnostic codes so you can check overall billings.
Understand and use the right modifiers.
2. Dictate documentation that provides a good history and reason for the procedures. Use ICD9 CM codes to their highest level
of specificity. Correlate them with the correct procedure code so staff can clearly understand what diagnosis supports each
procedure.
3. Code your visits and procedures quickly so the billing staff can get claims fled in a timely manner. Evaluation and management
of codes are important. Speed does matter.
4. Send electronic claims to as many payors as you can, and receive electronic payments from as many payors as you can. This
will increase the speed payment and save staff time. Any effective practice management system must edit and verify that all
claim form boxes are completed prior to sending claims electronically. An error on the patient's Social Security number or
birthday will generate a rejection.
5. Make sure billing staff has a good knowledge base about individual carrier contracts and policies. This makes the staff's follow
up much more effective. They need to know what documentation is required.
6. Dictate appeal letters to carriers as soon as requested. This allows staff to resubmit the claim quickly. Keep a template for
common requests. Know how to read Explanation of Benefit forms to respond to denials, incorrect bundling, down coding, and
designations of “experimental procedures.”
7. Keep abreast of reimbursement rules and regulations. Make sure that CPT books, carrier newsletters, and Medicare resources
are up to date, and send staff to as many coding seminars and conferences as possible.
8. Pay attention to accounts receivable. The billing staff needs to be sure to verify appropriate payments. Payers frequently do
not pay accurately or according to contracts. Don't allow accounts receivable to pile up. Leave clear parameters on what
information you want to review concerning overdue accounts.
Table 3.5 Usual and Customary Billed Charges—Physician Billings
Procedure CPT Code and 2008 Medicare RVUs2 2008 Medicare

Description1 National Average
For physician services provided in4
Physician Facility Physician Facility

Office5 Office5
Bone Marker 21499 Unlisted N/A 0 N/A Carrier

Fiducial musculoskeletal priced7
Placement6 procedure, head
64999 Unlisted N/A 0 N/A Carrier

procedure, nervous priced7
system
5/16/2015
Diagnostic 70450–26 CT, head 1.18 1.18 $41 $41
Imaging8 and or brain without
Planning9 contrast material10
70551–26 MRI, 2.05 2.05 $71 $71

brain, without
contrast material10
76376–26 3D 0.29 0.29 $10 $10

rendering with
interpretation and
reporting of computed
tomography,
magnetic resonance
imaging, ultrasound
or other tomographic
modality, not
requiring image
postprocessing on an
independent
workstation10
76377–26 3D 1.14 1.14 $40 $40

rendering with
interpretation and
reporting of computed
tomography,
magnetic resonance
imaging, ultrasound
or other tomographic
modality, requiring
image postprocessing
on an independent
workstation10
Lead 61863 Twist drill, N/A 38.09 N/A $1,357

Implantation11 burr hole, craniatomy,
or craniectomy with
stereotactic
implantation of
neurostimulator
electrode array in
subcortical site (e.g.,
thalamus, globus
pallidus, subthalamic
nucleus,
periventricular,
periaqueductal gray)
without use of
intraoperative
microelectrode
recording; first array
61864 Each N/A 11.90 N/A $433

additional array (List
separately in addition
to primary procedure)
61867 Twist drill, N/A 55.51 N/A $1,965

burr hole, craniotomy,
or craniectomy with
stereotactic
implantation of
neurostimulator
electrode array in
subcortical site (e.g.
thalamus, globus
pallidus, subthalamic
nucleus,
periventicular,
periaqueductal gray)
with use of
intraoperative
microelectrode
recording; first array
61868 Each N/A 16.82 N/A $605

additional array (List
5/16/2015
to primary
procedure.)
Generator 61885 (Soletra) N/A 15.15 N/A $544

Implantation or Insertion or
Replacement11,12 replacement of cranial
neurostimulator pulse
generator or receiver,
direct or inductive
coupling; with
connection to a single
electrode array
61886 (Kinetra) N/A 19.14 N/A $685

Insertion or
replacement of cranial
generator or receiver,
direct or inductive
coupling; with
connection to two or
more electrode arrays
For bilateral stimulation via implantation of two Soletra pulse generators, each
connected to a single lead, use 61885–50 plus 61863 and 61864 or 61867 and
61868. For bilateral stimulation via implantation of one Kinetra dualarray
pulse generator with connection to two leads, use 61886 plus 61863 and
61864 or 61867 and 61868.
Intraoperative 95961–26 Functional 4.55 4.55 $160 $160

Stimulation with cortical and
Microelectrode subcortical mapping
Recording13 by stimulation and/or
recording of
electrodes on brain
surface, or depth
electrodes, to provoke
seizures or identify
vital brain structures;
initial hour of
physician attendance
95962–26 Functional 4.68 4.68 $164 $164

cortical and
subcortical mapping
by stimulation and/or
recording of
electrodes on brain
surface, or depth
electrodes, to provoke
seizures or identify
vital brain structures;
each additional hour
of physician
attendance (List
to code for primary
procedure)
Revision or 61880 Revision or N/A 13.40 N/A $480

Removal of Leads removal of
or Generator11 intracranial
neurostimulator
electrodes
61888 Revision or N/A 10.10 N/A $361

removal of cranial
generator or receiver
Analysis and 95970 Electronic 1.35 0.61 $50 $21

Programming analysis of implanted
Note: In the office, neurostimulator pulse
analysis and generator system
programming may (e.g., rate, pulse
be furnished by a amplitude and
physician, duration,
practitioner with an confliguration of wave
5/16/2015
“incident to” benefit, form, battery status,
or auxiliary electrode selectability,
personnel under the output modulation,
direct supervision of cycling, impedance
the physician (or and patient
other practitioner), compliance
with or without measurements);
support from a simple or complex
manufacturer's brain, spinal cord, or
representative. The peripheral (i.e.,
patient or payor cranial nerve,
should not be billed peripheral nerve,
for services autonomic nerve,
rendered solely by neuromuscular)
the manufacturer's neurostimulator pulse
representative. generator/transmitter,
Contact your local without
carrier/payor for reprogramming
interpretation of
applicable policies.
95978 Electronic 5.58 4.84 $197 $168

analysis of implanted
generator system
(e.g., rate, pulse
amplitude and
duration, battery
status, electrode
selectability, output
modulation, cycling,
impedance and
patient compliance
measurements),
complex deep brain
generator/
transmitter, with
initial or subsequent
programming, first
hour
95979 Each 2.52 2.30 $88 $80

additional 30 minutes
after first hour (List
to code for primary
procedure.)
Evaluation and 99211–99215 Office 0.54–3.43 0.24–2.71 $20–$109 $8–$94

Management Note: or other outpatient
An office visit can visit
only be billed
separately when a
fullscale, separately
identifiable
evaluation and
management sevice
takes place in
addition to analysis
and programming.
The use of
evaluation and
management codes
may require a 25
modifier and must
meet separate
coding requirements
as well as
documentation
requirements.
99217–99220 N/A 1.85–4.06 N/A $65–$140

Observation care
99221–99223 Initial N/A 2.45–4.96 N/A $85–$172

hospital care
5/16/2015
99354–99355 2.52–2.56 2.38–2.43 $80–$90 $83–$85
Prolonged services,
office
99356–99357 N/A 2.34–2.35 N/A $82

Prolonged service,
inpatient
Data reprinted with 1 Current Procedural 2 Federal 3 Medicare 4 The 5 “N/A” 6 Placement 7 This is 8

the permission of Terminology (CPT) is Register, national RVUs shown in of implanted a carrier Preoperati
Medtronic, Inc. copyright 2007 Volume 72, average shown are Physician fiducials priced CT and MR
Copyright 2008. CPT American Model Number payment is for the Office should code. Imaging is
is a trademark of Association. All rights 227, determined by physician's setting generally be Carriers separately
American Medical reserved. No fee November applying the services indicates considered establish codable w
Association. schedules, basic units, 2007. The standard and that integral to the RVUs it represen
relative values or total RVU budget payment Medicare lead and the fullscale
related listings are as shown neutrality is made to has not implantation payment diagnostic
included in CPT. The here is the adjustor of the developed and should amount, imaging a
AMA assumes no sum of 0.8806 to the physician. RVUs in not be coded usually the
liability for the data three physician work However, the office separately on an interpreta
contained herein. components RVU there are setting when individual is
Applicable physician component, different because performed on case document
FARS/DFARS work RVU, then RVUs and the service the same day basis via a form
restrictions apply to 2008 multiplying the payments is typically as the lead after imaging
government use. transitioned sum of the depending performed implantation review of report. Int
(Continued on next practice three on the in a facility by the same the operative
page) expense component setting in (e.g., in a physician. procedure imaging is
RVU and RVUs by the which the hospital). Placement of report. part of
malpractice 2008 physician However, implanted surgical
RVU. The conversion rendered if the local fiducials can navigation
work RVU factor of the carrier be coded and should
must be $34.0682, as service. determines separately if not be cod
modified by published in “Facility” that it will performed separately
the CMS the Federal includes cover the during a Note that
budget Register, physician service in different although C
neutrality Volume 72, services the office, operative code 6179
factor in Number 227, rendered then it is episode on a exists for
order to November 27, in paid using previous date computer
calculate 2007. The hospitals, the facility or by a assisted
Medicare 2008 Medicare ASCs and RVUs at different surgical
payment. National SNFs. the facility physician navigation
Average Physician rate, per from the one National
reflects the RVus and the Federal who Correct
legislative payments Register, performed Coding
shortterm fix are Volume the lead Initiative
that replaced generally 72, implantation. (NCCI) ed
the 10.1% cut lower in Number Note that do not allo
with a 0.5% the 227, medical this to be
increase “Facility” November necessity coded
through June setting 27, 2007. must be separately
30, 2008. because demonstrated with lead
RVUs listed are the facility and implantati
not adjusted is documented codes 618
by the budget incurring for staging and 61867
neutrality the cost of the
factor. Final some of procedure.
payment to the
the physician supplies
is also and other
adjusted by materials.
the Geographic Physician
Practice Cosst RVUs and
Indices payments
(GPCI). are
Because GPCI generally
varies by area, higher in
each the
physician's “Office”
specific setting
reimbursement because
will vary from the
the national physician
average incurs all
payment costs
shown. Also there.
note that any
applicable
coinsurance,
5/16/2015
coinsurance,
deductible and
other amounts
which are
patient
obligations are
included in the
national
average
payment
shown.
Table 3.6 Comparisons of Deep Brain Stimulation Profitability
Medicare Hospital Contribution Hospital Net

Reimbursement Direct Margin Total Income/
Cost Cost Loss
Proposed Scenario 1
Inpatient admission (for insertion of lead) DRG 001 27,107 12,779 14,328 19,280 7827

Craniotomy age < 17 with Complications or Comorbidities
Outpatient Surgery (for insertion of pulse generator)* APC 11,877 7766 4111 11,535 342

222 Implantation of Neurological Device
DBS Procedure Totals 38,894 20,545 18,439 30,815 8169
Proposed Scenario 2
Inpatient admission (for insertion of lead) DRG 002 14,301 12,779 1522 19,280 (4979)

Craniotomy age <17 w/o Complications or Comorbidities
Outpatient surgery (for insertion of pulse generator)* APC 11,877 7766 4111 11,535 342

222 Implantation of Neurological Device
DBS Procedure Totals 26,178 20,545 5633 30,815 (4637)
Current Scenario 3
Inpatient admission (for insertion of lead) DRG 001 27,107 12,779 14,328 19,280 7827

Craniotomy age < 17 with Complications or Comorbidities
Inpatient Surgery (for insertion of pulse generator)* DRG 6464 7766 (1302) 11,535 (5071)

012 Degenerative Nervous System Disorder
DBS Procedure Totals 33,571 20,545 13,026 30,815 2756
Current Scenario 4
Inpatient admission (for insertion of lead) DRG002 14,301 12,779 1522 19,280 (4979)

Craniotomy age < 17 with Complications of Comorbities
Inpatient Surgery (for insertion of pulse generator)* 6464 7766 (1302) 11,535 (5071)
DRG 012 Degenerative Nervous System Disorder 20,765 20,545 220 30,815 (10,050)
DBS Procedure Totals
* There is also potential of $326 for APC 692—Electronic
Analysis of Neurostimulator Pulse Generators if done during
the visit as well. Numbers in parentheses are negative.
Values are set for 2003 and do not reflect the current
market, but are meant as examples of the variability that
exists with different approaches. You will need to calculate
for your particular market.
Conclusion
Movement disorder surgery, and functional neurosurgery in general, is still at the frontier of neurosurgical practice. Like all frontiers, there are several significant challenges that
must be faced. These include the technical, economic, organizational, and operational aspects of all the diverse elements that are involved in movement disorder surgery. By
carefully identifying all of these components one can develop a specific strategy that will allow a successful effort in this venture.
References
1. Maciunas RJ, Galloway RL Jr, Latimer JW. The application accuracy of stereotactic frames. Neurosurgery 1994;35:682–694 (discussion 694–695)
2. Leksell L. A stereotaxic apparatus for intracerebral surgery. Acta Chir Scand 1949;99:229–233
3. Leksell L. Stereotaxis and radiosurgery: an operative system. Springfield, IL: Charles C Thomas, 1971
4. Lunsford DL, Kondziolka D, Leksell D. The Leksell Stereotactic System. Stereotact Funct Neurosurg 1998;26:51–54
5. Cosman E. Development and Technical Features of the CosmanRobertsWells (CRW) Stereotactic System. In: Pell F, Thomas DG (eds.) Handbook of Stereotaxy Using
the CRW Apparatus. Baltimore: Williams & Wilkins; 1994: 1–52
6. Brown RA. A stereotactic head frame for use with CT body scanners. Invest Radiol 1979;14:300–304
5/16/2015
7. Riechert T. Beschreibung und Anwendung eines Zielgerates für stereotaktische Hirnoperationen. Acta Neurochir (Wien) 1956; (3 Suppl):308–337
8. Mundinger F, Boesecke R. The Riechert/Mundinger apparatus. In: Gildenberg PL, Tasker RR (eds.), Stereotact Funct Neurosurg. New York: McGraw Hill: 1998; 73–78
9. Henderson JM, Holloway KL, Gaede SR, Rosanow JM, Csavoy A. Frameless placement of deep brain stimulation electrodes: an accuracy study. Mov Disord
2004;19(Suppl 9):S302
10. Guridi J, RodriguezOroz MC, Ramos E, et al. Discrepancy between imaging and neurophysiology in deep brain stimulation of medial pallidum and subthalamic nucleus
in Parkinson's disease. Neurologia 2002;17:183–192
11. Priori A, Egidi M, Pesenti A, et al. Do intraoperative microrecordings improve subthalamic nucleus targeting in stereotactic neurosurgery for Parkinson's disease? J
Neurosurg Sci 2003;47: 56–60
12. Hariz MI. Is microelectrode recording necessary in movement disorder? The case against. In: Israel Z, Burchiel KJ, eds. Microelectrode Recording in Movement
Disorder Surgery. New York: Thieme; 2004:197–207
13. Sierens DK, Bakay RAE. Is microelectrode technique necessary in movement disorder surgery? The case in favor. In: Israel Z, Burchiel KJ, eds. Microelectrode
Recording in Movement Disorder Surgery. New York: Thieme; 2004:186–196
14. Slavin KV. Intraoperative microrecording equipment: comparative analysis of commercially available microrecording systems. Neurol Res 2002;24:544–554
15. Steinmeier R, Rachinger J, Kaus M, et al. Factors influencing the application accuracy of neuronavigation systems. Stereotact Funct Neurosurg 2000;75:188–202
16. Abbasi HR, Hariri S, Martin D, et al. A comparative statistical analysis of neuronavigation systems in a clinical setting. Stud Health Technol Inform 2001;81:11–17
17. Troster AI. Introduction to neurobehavioral issues in the neurosurgical treatment of movement disorders: basic issues, thalamotomy, and nonablative treatments.
Brain Cogn 2000;42:173–182
18. Woods SP, Fields JA, Troster AI. Neuropsychological sequelae of subthalamic nucleus deep brain stimulation in Parkinson's disease: a critical review. Neuropsychol Rev
2002;12:111–126
19. Jankovic J. Classification and epidemiology of movement disorders. In: Krauss JK, Grossman RG, eds. Surgery for Parkinson's Disease and Movement Disorders.
2001:21
20. Patil AA. The Patil apparatus. In: Tasker P, Gildenberg P, eds. Textbook of Functional and Stereotactic Neurosurgery. New York: McGrawHill; 1998:105–111
21. Hariz MI, Laitinen L. The Laitinen apparatus. In: Tasker P, Gildenberg P, eds. Textbook of Functional and Stereotactic Neurosurgery. New York: McGrawHill;
1998:87–94
22. Goerss SJ. The COMPASS system. In: Tasker P, Gildenberg P, eds. Textbook of Functional and Stereotactic Neurosurgery. New York: McGrawHill; 1998:151–162
23. Zamorano L, The ZamoranoDujovny Multipurpose Localizing Unit. Advanced Neurosurgical Navigation. New York: Thieme; 1999: 255–266
24. Benabid AL, Hoffman D, LeBas JF, Munari C. The Talairach system. In: Tasker P, Gildenberg P, eds. Textbook of Functional and Stereotactic Neurosurgery. New
York: McGrawHill; 1998:79–86
25. Sugita K, Mutsuga N. The Sugita apparatus. In: Tasker P, Gildenberg P, eds. Textbook of Functional and Stereotactic Neurosurgery. New York: McGrawHill;
1998:131–137
Printed from Thieme eNeurosurgery on 1652015 by user@thieme.de
© 2011 Thieme Medical Publishers, Inc. All Rights Reserved

3 Setting Up A Movement Disorder Surgery Practice

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

3 Setting Up A Movement Disorder Surgery Practice

Uploaded by

Copyright:

Available Formats

5/16/2015

Globally, the Leksell Stereotactic System ( Fig. 3.1 ) is the most widely used frame. The frame, designed by Lars Leksell in 1949 [2] after his period of study with Spiegel and

The second most common headframe used in the United States, the CRW Stereotactic Apparatus is another arccentered system. The CRW frame ( Fig. 3.2 ) is the second

Developed by Fritz Mundinger and Traugott Riechert in 1951. [7] this device is a popular stereotactic system in Europe. The RM frame ( Fig. 3.3 ) is a polar coordinate system

System Name Guideline— Stim Pilot MicroGuide

Manufacturer FHC, Inc. Medtronic Functional Alpha­Omega Engineering

Distributor FHC, Inc. Medtronic Nicolet (US/Asia)/Alpha­Omega

Price Range ($US) $50k­$100k $60k­$80k $75k­$100k

Contact (207) 666–8190 (800) 328–0810 (877) 919–6288

www.fh­ www.medtronic.com www.alphaomega­eng.com

The most prevalent commercial systems are manufactured by Medtronic, Radionics, Elekta, and BrainLab ( Table 3.2 ). Each has its own limitations and advantages. [15] , [16]

System Name Treon Plus StealthStation: SurgiPlan/ Leksell SurgiPlan VectorVision: iVision

Manufacturer Medtronic Surgical Navigation Radionics Elekta BrainLab

Distributor Medtronic Radionics Elekta BrainLab

Price Range ($US) $253,500 (Frame and $100,000– $85,000 (Leksell­ $250,000 + (Frame and

Contact (877) 242–9504 (781) 272–1233 (770) 300–9725 (800) 784–7700

www.stealthstation.com www.radionics.com www.elekta.com www.brainlab.com

Our personal preference is for a metal frame. We recognize in a small practice a plastic frame might be of some value, [20] but they simply do not hold up in high­volume practices.

Procedure CPT Code and 2008 Medicare RVUs2 2008 Medicare

Physician Facility Physician Facility

Bone Marker 21499 Unlisted N/A 0 N/A Carrier

64999 Unlisted N/A 0 N/A Carrier

70551–26 MRI, 2.05 2.05 $71 $71

76376–26 3D 0.29 0.29 $10 $10

76377–26 3D 1.14 1.14 $40 $40

Lead 61863 Twist drill, N/A 38.09 N/A $1,357

61864 Each N/A 11.90 N/A $433

61867 Twist drill, N/A 55.51 N/A $1,965

61868 Each N/A 16.82 N/A $605

Generator 61885 (Soletra) N/A 15.15 N/A $544

61886 (Kinetra) N/A 19.14 N/A $685

Intraoperative 95961–26 Functional 4.55 4.55 $160 $160

95962–26 Functional 4.68 4.68 $164 $164

Revision or 61880 Revision or N/A 13.40 N/A $480

61888 Revision or N/A 10.10 N/A $361

Analysis and 95970 Electronic 1.35 0.61 $50 $21

95978 Electronic 5.58 4.84 $197 $168

95979 Each 2.52 2.30 $88 $80

Evaluation and 99211–99215 Office 0.54–3.43 0.24–2.71 $20–$109 $8–$94

99217–99220 N/A 1.85–4.06 N/A $65–$140

99221–99223 Initial N/A 2.45–4.96 N/A $85–$172

99356–99357 N/A 2.34–2.35 N/A $82

Data reprinted with 1 Current Procedural 2 Federal 3 Medicare 4 The 5 “N/A” 6 Placement 7 This is 8

Medicare Hospital Contribution Hospital Net

Inpatient admission (for insertion of lead) DRG 001 27,107 12,779 14,328 19,280 7827

Outpatient Surgery (for insertion of pulse generator)* APC 11,877 7766 4111 11,535 342

DBS Procedure Totals 38,894 20,545 18,439 30,815 8169

Inpatient admission (for insertion of lead) DRG 002 14,301 12,779 1522 19,280 (4979)

Outpatient surgery (for insertion of pulse generator)* APC 11,877 7766 4111 11,535 342

DBS Procedure Totals 26,178 20,545 5633 30,815 (4637)

Inpatient admission (for insertion of lead) DRG 001 27,107 12,779 14,328 19,280 7827

Inpatient Surgery (for insertion of pulse generator)* DRG 6464 7766 (1302) 11,535 (5071)

DBS Procedure Totals 33,571 20,545 13,026 30,815 2756

Inpatient admission (for insertion of lead) DRG002 14,301 12,779 1522 19,280 (4979)

Inpatient Surgery (for insertion of pulse generator)* 6464 7766 (1302) 11,535 (5071)

DRG 012 Degenerative Nervous System Disorder 20,765 20,545 220 30,815 (10,050)

You might also like

Manufacturer FHC, Inc. Medtronic Functional AlphaOmega Engineering

Distributor FHC, Inc. Medtronic Nicolet (US/Asia)/AlphaOmega

Price Range ($US) $50k$100k $60k$80k $75k$100k

www.fh www.medtronic.com www.alphaomegaeng.com

Price Range ($US) $253,500 (Frame and $100,000– $85,000 (Leksell $250,000 + (Frame and

Our personal preference is for a metal frame. We recognize in a small practice a plastic frame might be of some value, [20] but they simply do not hold up in highvolume practices.